Medicaid and Medicare Advantage Performance Standards for Home Care Providers

Medicaid and Medicare Advantage Performance Standards for Home Care Providers

Home care is an important benefit for many Medicare Advantage and Medicaid recipients. The problem, though, is how are home care benefits being measured and assessed?

Have you worked with a Medicare Advantage plan yet as part of their home care and supportive service offerings? Roughly half of older adults and Medicare-eligible members chose to use Medicare Advantage for their benefits over Original Medicare. 

One of the chief reasons is because of the additional value-added benefits they offer on top of the existing regimen like dental and medical care. 

What has been missing from the Medicare Advantage equation is the oversight and measurement of care delivery, particularly for not primarily health-related benefits. Here’s an overview of what we’ll talk about today: 

  • How Medicaid has been leading the charge.
  • Performance standards that home care providers can focus on
  • Medicare’s room to grow

How Medicaid has been leading the charge.

Medicaid has served as an example of innovative care delivery for diverse patient populations and groups. Medicaid Managed Care and similar programs via waivers have proven to not only lower barriers to care but also demonstrate efficacy in the form of performance measures. This could include measurement by: 

  • Healthcare Effectiveness Data and Information Set (HEDIS)
  • Consumer Assessment of Healthcare Providers and Systems (CAHPS)
  • Core sets (which differ based on discipline and population group)
  • HCBS Quality Measure Set
  • Long-Term Services and Supports (LTSS) Quality Measures
  • Specific measures set by state or plan needs (As an example, here is how MassHealth measures the health of members and assess plan performance.)

What these sets of performance measures do is establish objective ways to assess, critique, and improve the delivery of care across multiple sides of operations. 

Performance Standards That Home Care Providers Can Focus On

There are many ways to assess how care is delivered, but what does that mean for your home care agency? The standards set for payers are a golden ticket for you to develop and nurture relationships with payers and other key stakeholders. 

For example, with Long-Term Services and Supports, here are a few metrics that you can focus on. 

Assessment and care planning

This is one of the first impressions you make on a client. Coming into the home, you have an opportunity to explore beyond what a client says they need help with. 

If you haven’t already, work toward moving beyond paper care planning. Document these in your agency management system for seamless information sharing with your team, caregivers, clients, family members, and other key stakeholders. 

Assessments that meet the mark have to include the following elements

  1. Status of at least five activities of daily living
  2. Any acute or chronic health conditions
  3. Any medications they are taking
  4. Assessment of cognitive function (using a standardized tool like MoCA)
  5. Assessment of mental health status (using a standardized tool like DEPS)
  6. Any home safety risks 
  7. How the person lives (at a home or in a community, etc…)
  8. Current and future family caregivers or support (with their contact information and availability)
  9. Contact information for any known providers (like primary care, specialists, etc..)

Using care plans that are thorough and go into detail will not only streamline communication within your team, but make life easier for your caregivers having one place to reference this information. It’s especially helpful if they take a client to an appointment. 

Fall risk assessment

Although you can’t prevent every fall from happening, when caring for clients it is important to assess their home for safety but also understand what might put the client at a higher risk for falling. 

For Medicaid, fall prevention is an important performance measurement and taking the proper steps to make sure that you keep clients safe should be a top priority. Work together with any other providers that see the client and make sure you’re on the same page. Here are some best practices: 

  • Share any important medication information with caregivers. Some medications like ones that manage anxiety, blood pressure, and overactive bladder are a few examples. 
  • If clients have a bedroom that’s not on the first floor, make sure that caregivers are present before they go up or downstairs. 
Rebalance and utilization

One-third of seniors fall each year. Maintaining balance can become increasingly hard as they age. One of Medicaid’s goal in this category for providers to help clients:

  • Reduce admission to a facility from the home
  • Decrease length of stay when admitted to a facility
  • Transition home successfully after being admitted into a facility

Again, not all falls or balance issues are preventable, but home care providers like you share a responsibility with the family to keep the client safe and healthy at home. 

How can you help clients and providers when it comes to balance?

  • Educate clients and family members on exercises and ways to maintain balance (like toe raises and wall push-ups, for example)
  • Work with your nurses and other administrative staff to create a hospital-to-home and skilled nursing-to-home program that helps clients transition smoothly back home. 
  • Perform an audit after any events to assess what happened and what could’ve been done to prevent this from happening (if applicable). 
  • Follow up with family members and facility staff members as permitted. You may be able to continue visits while they’re away from home and help decrease their length of stay.

Those are the three performance measure categories for long-term services and supports. Here’s how Medicare can do better in following Medicaid’s footsteps. 

Medicare’s room to grow

Let’s set the stage. Seniors are continuing to make the choice to switch from Original Medicare to Medicare Advantage, in the hopes that they can have choice, lowered costs, and access to additional benefits.

According to a recent report from Leavitt Partners, “Beneficiary demand for—and inconsistent data collection and inconsistent oversight of—promising supplemental MA benefits has created a $70 billion black box that should be illuminated and strengthened using established accountability measures from the Medicaid program.”

What does this mean? 

Medicare Advantage plans hopped onto the idea of value-added benefits early on, which is great. However, they didn’t put proper checks and balances in place to ensure that the quality of benefit delivery met member expectations. And did they improve member health outcomes? That is the unknown here. 

Firstly, Medicare Advantage (MA) plans used independent contractors to supply caregivers. This created a unique set of challenges for assessing care quality from the client’s and payer's sides. 

Payments to MA plans have grown over the last several years, but what we need to find out is: 

  • What benefits are plans offering?
  • What are beneficiaries using?
  • What is the quality of home care from each provider (and how does it vary)?
  • How are providers and benefits overseen?
  • What is the ROI from these federal investments?

The report recommends using Medicaid’s regulated approach to home care (relying on home care agencies over independent contractors), and utilizing set standards to measure beneficiary care and provider quality. 

Expand your home care offerings to Medicare Advantage plans.

2024 is the year for exploring new opportunities for your payer source mix

We are optimistic as the growing number of supplemental benefits continues to acknowledge taking in member feedback and offering what people want. If your agency is looking for a new agency management system that’s able to manage the payer mix you’re developing, consider switching to CareTime today


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